Child Binocular Vision Dysfunction Questionnaire

Child Questionnaire

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Introduction

If you think that you might have Binocular Vision Dysfunction, please fill out this Questionnaire. We will interpret your responses and contact you regarding the results.

If you would like to tell us more about your symptoms, please write about them in the Comment Section at the end of the Questionnaire. We will combine this information with the responses you gave in the Questionnaire to provide you with a more detailed interpretation of the results.

Please Note: We will not sell or otherwise use information on this form except in addressing your inquiry. Please see our Privacy Policy.

Contact Information

Name*

FirstLast

Your Age*

Best Phone Number*

Alternate Phone Number

Email*

State and Country*

StateCountry

Best Day to be Contacted

Best Time to be Contacted

Next Best Day to be Contacted

Next Best Time to be Contacted

Directions

Children - answer these questions together with your Parents. For every question, select the answer that best describes your situation. If you wear glasses or contact lenses, answer the questions assuming that you are wearing them. Please answer every question.

Never = Never
Occasionally = Less than 1 time / week
Frequently = At least 1 time / week
Always = Everyday

1. Do you have headaches or face pain?*

Never

Occasionally

Frequently

Always

2. Do your eyes hurt and/or does it hurt to move your eyes?*

Never

Occasionally

Frequently

Always

3. Do you have neck pain or a stiff neck or upper back pain?*

Never

Occasionally

Frequently

Always

4. Do you have stomach aches or nausea?*

Never

Occasionally

Frequently

Always

5. Do you get car sickness or motion sickness?*

Never

Occasionally

Frequently

Always

6. Did you get sick in the car seat when you were a small child?*

Never

Occasionally

Frequently

Always

7. Do you get sick to your stomach or nauseous on swings or circular rides?*

Never

Occasionally

Frequently

Always

8. Does riding in the car give you headaches or stomach aches?*

Never

Occasionally

Frequently

Always

9. Do you have trouble reading in the car?*

Never

Occasionally

Frequently

Always

10. Do you feel clumsy or klutzy or uncoordinated?*

Never

Occasionally

Frequently

Always

11. When you are walking, do you bump into people or furniture or door frames?*

Never

Occasionally

Frequently

Always

12. Do you feel funny or dizzy when you bend over and stand back up quickly?*

Never

Occasionally

Frequently

Always

13. Are you anxious or nervous?*

Never

Occasionally

Frequently

Always

14. In grocery stores or malls, do you stay close (cling) to your Mom or Dad?*

Do you feel uncomfortable in grocery stores or malls?

Never

Occasionally

Frequently

Always

15. Is reading hard for you or are you a slow reader?*

Never

Occasionally

Frequently

Always

16. Do you experience double / overlapping / shadowed vision at near distances?*

Never

Occasionally

Frequently

Always

17. Do you have to read the same thing a couple of times to really understand it?*

Never

Occasionally

Frequently

Always

18. Do you use your finger or a ruler or a piece of paper to help you keep your place when you are reading?*

Never

Occasionally

Frequently

Always

19. Do you skip lines or lose your place when you are reading?*

Never

Occasionally

Frequently

Always

20. When you read, does it look like letters are moving or does it seem like words are bumping into each other?*

Never

Occasionally

Frequently

Always

21. Do bright lights hurt your eyes?*

Never

Occasionally

Frequently

Always

22. Do you close or cover one eye to make it easier to see?*

Never

Occasionally

Frequently

Always

23. Do you have trouble catching baseballs, footballs, or frisbees?*

Never

Occasionally

Frequently

Always

24. Do you ever see two of everything (double vision)?*

Never

Occasionally

Frequently

Always

25. Is it hard for you to watch 3-D movies?*

Never

Occasionally

Frequently

Always

26. When reading or working on the computer, do your eyes feel tired or does your vision get blurry?*

Never

Occasionally

Frequently

Always

27. When looking at the blackboard at school, do your eyes feel tired or does your vision get blurry?*

Never

Occasionally

Frequently

Always

Mom / Dad: Has your child ever been diagnosed with:

Learning disability (LD)?*

Yes

No

Reading disability?*

Yes

No

Dyslexia?*

Yes

No

ADD / ADHD?*

Yes

No

Torticollis?*

Yes

No

Migraines or headache disorder?*

Yes

No

Lazy eye?*

Yes

No

Traumatic brain injury or concussion?*

Yes

No

Does your child blink their eyes a lot / much more than most children?*

Yes

No

Are your child's verbal skills far ahead of their reading skills?*

Yes

No

Has your child ever had an eye operation?*

Yes

No

How frequent do you experience:

On an average day, how much are you bothered by the symptoms listed below? (Rate each symptom from 0 to 10, where 10 is the worst it could be, and where 0 means you have none of that symptom)

Dizziness*

Nausea*

Anxiety*

Headache*

Neckache*

Unsteady with walking*

Sensitivity to light*

Reading difficulty*

Have more to share?

Comment Section

If you want to tell us more about you symptoms, or if you have specific questions, record them here.

Tell us how you found us.*

Internet Search

Referred by a Friend

Referred by a Professional

Forum, Blog or Social Media

Please explain*

Internet Search: Please include the keywords you used
Referred by a Friend or Professional: Please let us know who.
Forum, Blog or Social Media: Which one?
Other: Please explain | Heard about us - where?

Please Note: We will not sell or otherwise use information on this form except in addressing your inquiry. Please see our Privacy Policy.

BVD Score

SSI Score

Our Patients Say

I could feel my symptoms start to go away after the first office visit.

My headaches, neck ache and eye pain are so much better since I started wearing my new prism glasses.

My dizziness is completely gone after wearing my new glasses.

Browse the Video Testimonials

Testimonials

Have you ever felt dizzy and anxious when driving or riding in a car? If so, you could be experiencing one of the many symptoms of vertical heterophoria (VH), a binocular vision dysfunction caused by a misalignment of the eyes. This misalignment is typically the result of a head injury, but it can also occur when one eye is physically set a little higher than the other, causing the eyes to see images at slightly different levels. How the Brain Responds to VHThe brain i…

How We Help Patients Overcome Dizziness While Driving

For years I have suffered from migraines and more recently severe neck pain. Dr. Cheryl took one look at me and knew what was wrong. She explained that my neck pain was due to tilting my head to compensate fro my vision deficits. Tilting my head was a way to stabilize my vision but it was taxing my body. She asked me a variety of questions, which ranged from when I experience pain to how I feel in crowds. I would have never known that all of my anxieties in crowded places and my inability to wal…

D.V.

I never really had headaches before this year, but my balance felt off, I felt crooked. We went to a lot of doctors until my pediatrician said to go to the eye doctor. I suffered academically and socially because the headaches started to get worse and they were constant. They rarely let up. The morning was the worst, I was nauseous every morning. This went on for three months until I came to Dr. Israeloff. We never thought it was my eyes because my eyesight was always fine!
What a wonderful s…

M. L.

Prior to being treated by Dr. Cheryl, I constantly felt off balance. I had suffered from frequent migraines since I was 12 years old. I often suffered from neck/ back pain, and always felt like I was straining my neck and/or tilting my head to focus on the computer. My family had always noticed that I walked a bit sideways as well, but they attributed that to me being “clumsy”. I had awful anxiety about walking down flights of stairs or through the mall, as I always had this irrational fear of f…

A. S.

My family would always tease me about how clumsy I was. I couldn’t even walk in a straight line. This got worse as I got older until I tripped and fell in the subway. I became so nervous to go out because I couldn’t walk straight or judge how to step off a curb. I consulted many doctors who diagnosed me with anxiety disorder. I really didn’t think I had anxiety disorder at all. I was anxious because I was afraid I was going to fall due to my poor depth perception. I learned about Dr. Debby Feinb…

N. S.

Unfortunately, I have been suffering from migraines since I was 7 years old. I spent countless hours in doctors’ offices trying to resolve this issue but was left unrewarded. I started wearing glasses when I was in elementary school but they did not relieve my headaches. Being an active child, I found that these headaches hindered my ability to participate in certain activities. As the years went on the headaches became more frequent and debilitating, leaving me with symptoms of nausea, vomiting…

D.V.

Unfortunately, I have been suffering from migraines since I was 7 years old. I spent countless hours in doctors’ offices trying to resolve this issue but was left unrewarded. I started wearing glasses when I was in elementary school but they did not relieve my headaches. Being an active child, I found that these headaches hindered my ability to participate in certain activities. As the years went on the headaches became more frequent and debilitating, leaving me with symptoms of nausea, vomiting…

I was never happy with my vision. I always felt things didn’t look quite right. Everyday, I would suffer from eyestrain and tension at my temples. I went to many eye doctors and they all said my eyes were fine. At a routine eye appointment with Dr. Cheryl, I complained about these feelings of strain and eye pain. She asked tons of questions and did the most detailed eye exam that I ever had. She not only tested my vision in each eye but she tested how my two eyes worked together. My problems wer…

S. H.

Who, indeed, could have supposed that a mere ocular defect could have given rise to so serious a train of evils….And who that had not seen it, could believe that the correction by glasses of the eye trouble could have given a relief so speedy and so perfect that the patient described it as a miracle?